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STATE OF CALIFORNIA <br /> P i <br /> STATE WATER RESOURCES CONTROL BOARD a GROUND STORAGE STORAGE TANK PERMIT APPLICATION - FORM A �� Y <br /> ONN• <br /> COMPLETE THIS FORM FOR EACH FAerI <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P Y CLO ED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT [—] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITYN>11,E kl NAME OF OPERATOR <br /> ADDRESS . NEAREST CROSS STREET PARCEL#IOPTIONAu <br /> CITY NAMEZji STATE ZIP CODE <br /> r—� � / SITE PHONE#WITH AREA CODE <br /> BOX <br /> CA 6 <br /> TO INDCATE O CORPORATION 0 INDIVIDUAL 0 PAR ERSHIP O LOCAL-AGENCY D COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O I/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 3 FARM = 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) ONE"I1II_AIIFA_QQDF__ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box blMiwte D INDIVIDUAL OLOCAL-AGENCY (] STATE AGENCY <br /> =CORPORATION = PARTNERSHIP Q COUNTY-AGENCY E-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box 0intlbala 0 INDIVIDUAL I= LOCAL-AGENCY 0 STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST B 0LMP ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box toin&ale 1 SELF-INSURED = 2 GUARANTEE 0 ] INSURANCE <br /> (� D d SURETY BONG <br /> 5 LETTEROFCREDIT <br /> = 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING; I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE MONTH/DAY/Y <br /> LOCAL AGENCY USE ONLY S J <br /> COUNTY# JURISDICTION If FACILITY It <br /> LOCATION 11- CENSUS TRAr6-_QUPTIONAL SUPVISOR-DISTRICT CO E - T/ONAL <br /> THIS FORM MUST BE ACCOMPANIED W AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, U LESS THIS IS A CHAN F SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> //;�„ FORW]9A.5 <br />